WQCSD0090_WPCSOCC Form_20240414

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Permittee Owner/Officer Name:
Mailing Address:
City:
Email Address:
Signature:
Pr Tea
information
cA0 ice— State: R L
Facility Name: 11 %uLo CCA\CC--i"A14
County: M:L �L�l,n
Z
Zip: .7 15 5 5
Date: _ 3--`q� ---� y
Permit # Woc5DaQ9S&)
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type:
CS�
Facility Grade:
11
Print Full Name: f'
Certificate Type: CS
Email Address: phi
Signature:
Certificate Grade: 11
Work Phone: 01 S,}- q (-<-- 7,V 13
Certificate #: 1014353
Date: 711112
"I certify that I agree to my designation as the Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the respansiblWes of the ORC us set forth in 15A NCAC 086.0204 and failing to do so can result in
nisciplinary Actions by the Water Pollution Control system Operators Certification Commission.`
Print Full Name: \
Certificate Type: C5
Email Address:
rC o w (N\\ 3L- Work Phone: 9)9 QQ ik-
Certificate Grade: 11 Certificate #:1014348
Signature: �® Date:
"i certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted l understand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC as set forth in INi NCAC 08G .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail, fax or email WPCSOCC,1618 Mail Service Center, Fate 919-715-2726 Em�tiGeertadmin_ L&rtcdenr.8ov
ORIGINAL to: Raleigh. NC 27699-1618
Mail or Fax Asheville
a COPY to: 2090 US Hwy 70
Swannanoa, NC 23778
Fax.[phone]
Phone:[phone]
Washington
943 Washington Sq- Mail
Washington, NC 27M
Fax!252-946-9215
Phone:[phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax: [phone]
Phone,910-433-3300
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax:[phone]
Phone. [phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax:[phone]
Phone: [phone]
Winston-Salem
45 W. Hanes Mall Rd.
Winston-Salem, NC27105
Faw 336.776-9797
Phone:[phone]
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone:[phone]
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